Neck Dissection
=Introducción= Neck dissections are performed for tumors of the head and neck (e.g., pharyngeal cancer, laryngeal cancer, thyroid cancer). Levels I-VI can potentially be present. Radical neck dissection includes internal jugular vein and sternocleidomastoid muscle. We more commonly receive modified neck dissections that lack IJV and SCM, and may include only selected lymph node levels. The easiest way to get a neck dissection is as several disaggregated levels (i.e., each level is submitted as a separate specimen). Other specimens will come up as a single larger piece of tissue, and will need to be oriented by the surgeon. Sometimes this is done in the OR by suturing the specimen to a piece of glove paper. Other times, the surgeon will come to the pathology suite to orient the specimen. Some issues to keep in mind: *Know why the procedure was done. Was there an FNA of a neck mass? (Find the mass.) Did the person have papillary thyroid cancer? (Then this dissection may be for staging-—no lesion expected.) *You need the surgeon to help you orient the specimen. If sufficient orientation is not provided with the requisition, contact the ENT fellow or attending. Often, the surgeon will come to surgical pathology to orient complicated specimens. *The surgical pathology attending should be contacted if there is any difficulty regarding orientation of the specimen prior to dissection. Several types exist: (Note: We do not usually have to worry about this) *Modified radical type I: En bloc removal of the lymph-node-bearing tissues of one side of the neck, includes internal jugular and sternocleidomastoid *Modified radical type II: En bloc removal of the lymph-node-bearing tissues of one side of the neck, includes sternocleidomastoid *Modified radical type III: En bloc removal of the lymph-node-bearing tissues of one side of the neck. Spares IJV, SCM and spinal accessory nerve. *Anterolateral neck dissection: En bloc nodes from I, II and III *Lateral neck dissection: En bloc nodes from II, III and IV *Posterolateral neck dissection: En bloc nodes from II, III, IV and V *Anterior neck dissection: Removal of the pretracheal and paratracheal node groups. =Fresh Handling= *At the frozen bench, the most important task is to get the specimen oriented and pinned out. (If submitted as multiple separate specimens, this is not an issue.) *If bulky disease is grossly apparent, some tumor can be taken for tissue banking. *Specimen can then be fixed in formalin overnight. Note: Specimen may also be grossed fresh. =Grossing In= For larger specimens including multiple levels: *Describe the overall dimensions of the specimen and the type of orientation provided (e.g., "The specimen consists of a neck dissection measuring 15 x 6.5 x 1.5 cm. Levels I-IV are designated by the surgeon."). *For each level, describe dimensions and major contents (nodes, salivary glands, muscle, internal jugular vein). *Include largest dimension of largest node present in each level (e.g., "The portion designated as Level I measures 4.3 x 3.4 x 1.5 cm and contains multiple potential lymph nodes measuring up to 0.9 cm."). *For each level, if the amount of tissue is small (<10 cassettes), submit entirely. *If the tissue is larger, it does not need to be submitted in toto. *All grossly negative lymph nodes should be submitted entirely. *If a node is grossly positive, it does not need to be submitted in toto. Submit one or more representative sections to demonstrate involvement and to query for extracapsular extension. The section should be taken through the hilum, since this is where extracapsular extension is most common. *Additional soft tissue that does not grossly contain nodes does not need to be submitted. Later, if you don’t have enough nodes, you will have to go back and put this tissue in. *Large nodes may need to be bisected. The gross description must make it possible to determine which lymph node profiles represent a bisected node. **Good: One node bisected in one cassette. **Good: One node bisected and submitted in two cassettes. **Not good: Two nodes bisected and submitted in one cassette. If two profiles contain tumor, you will not know if this represents 1/2 or 2/2. *Include one section of any salivary gland, muscle or vein. Remaining soft tissue from each level should be packaged in a labeled mesh baggie or folded paper towel so that it can be identified again if necessary. *If a level includes gross tumor, submit as many sections as you need to demonstrate the relation of the tumor to adjacent structures. Note: This is not common. For cases that have been requisitioned as multiple separate levels: *Handle each level according to steps 2-7 above. =Sample dictation= For salivary gland, if present and unremarkable: Level I contains a submandibular gland measuring ___ x ___ x ___ cm, with a tan-brown surface, sectioned to reveal no grossly apparent lesions. For salivary gland with a salivary gland tumor: The gland is serially sectioned to reveal a solitary, solid/cystic, round/ovoid/irregular, well/poorly circumscribed nodular lesion, measuring ___ cm, ___ in color, soft/firm/hard/gelatinous/rubbery/friable in consistency, with a well/ill defined capsule, with/without focal infiltration of the lesional capsule, with a homogenous/heterogenous, smooth/irregular, fleshy/variegated cut surface, with/without areas of hemorrhage and necrosis, with a central/peripheral fibrotic scar (possibly representing the prior FNA site), situated in the ___ portion of the salivary gland, ___ cm from the nearest outer inked capsular surface, but not grossly infiltrating through it. The remaining margins are ___. Serial sectioning of the remaining gland reveals no other grossly apparent lesions. For a level of a neck dissection, containing nodes: The portion designated as level IIA measures ___ x ___ x ___ cm and is dissected to reveal multiple potential lymph nodes measuring from ___ up to ___ cm in diameter. (One potential lymph node appears to be hemorrhagic, necrotic, showing cystic degeneration OR shows areas of necrotic cystic degeneration, possibly representing tumor). Level IIA is submitted in toto as/ Representative sections of Level IIA are submitted as follows: Sections of potential salivary gland/ potential lymph node in ___ ; bisected potential lymph nodes in ___. =Review and Signout= Retrieve the patient’s primary tumor slides, if available, to let you know what you are looking for. In your previewing, if you have a positive node, look for areas where the tumor extends out of the node—an important prognostic factor. Sample diagnostic lines: 1. Lymph nodes, levels I-IV, modified neck dissection: :A. No tumor seen in 35 lymph nodes (0/35), see microscopic description. :B. Submandibular gland, no tumor seen. 1. Lymph nodes, levels I-IV, modified neck dissection: :A. Metastatic tumor present in one of 35 lymph nodes (1/35), with extracapsular extension, smd(F9). :B. Submandibular gland, no tumor seen. In the diagnosis, you can group all the levels together. The microscopic description should include a template for neck dissections, specifying which levels had positive nodes. ---- Return to Head and Neck